RISE Application

Please use the form below to apply for Project RISE:

1 Start 2 Complete

First name: *

Last name: *

Date of birth: *

Month

Day

Year

Participant's email: *

Participant's phone number: (including area code) *

Use only digits, no dashes.

Participant's home Address: *

Address line 2:

City: *

State: *

Zip or postal code: *

What is the medically diagnosed condition causing the participant's loss of or low vision? *

Does the participant have additional disabilities, in addition to vision loss?

Age of Participant (as of August 2023): *

Parent or guardian full name: *

If participant is above the age of 18, please list emergency contact information.

Please describe your relationship to the participant if other.

Contact's email: *

Contact's phone number: *

Contact's address: *

Address 2:

City *

State *

Zip or postal code *

Name of TBS/TVI: (if applicable)

TBS/TVI Phone Number:

Name of Vocational Rehabilitation Counselor:

Name of Orientation and Mobility Instructor: (if applicable)

In which school is the participant enrolled? *

What year of school is the participant currently in? *

What is the participant's primary reading medium? *

What is the participant's height? *

Does the participant use a cane, guide dog, or neither?

Does the participant have any dietary restrictions or allergies? If so, please describe in detail: *

Leave this field blank

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